GW1--07769_Well Construction - GW1_20231201

•
WELL CONSTRUCTION'RECORD . For Internal Use ONLY:
This form can be used.for single or.multiple wells
1.Well Contractor Information: :;,
KENNY$.ARGENT I4 OATERZONES.. ' • . ., _. I -.
FROM TO' DESCRIPTION • •.
•
Well Contractor Name ft. ft.
A =4226 ft. ft. 1 •
• NC Well Contra torCertification Nurnber 15.OUTERCASING(for multi.cased wells)OR LINER(if ap-licable) '
•FROM ' .TO .- ' DIAMETER - THICKNESS . MATERIAL '
• : GEOLOGIC"EXPLORATION ft. . .- • .ft:. '.' . I .' in.
Company Name ' . 16.INNER CASING OR TUBING(geothermal closed:loop) • .. ' .' • ' •
70001364/WM0301318 FROM TO' DIAMETER THICKNESS MATERIAL ". ,
2.Well Construction Permit#: , ft. • ft. . ,In. '
List all applicable well construction permits(i.e.County,State,Variance,etc.)
• tt. ft in.
3.Well Use(checkwell use): , •
17i SCREEN
Water Supply Well: 'FROM . TO' . . • DIAMETER' 'SLOT SIZE. THICKNESS. MATERIAL•
.ft. 'ft.. In.
❑Agricultural . •❑Municipal/Pubfic
' • ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) •. ft. • .fG in., .
❑Industrial/Commercial• .OResidential Water Supply(shared). -1S.GROU .
T . ' " • ' ' •- " • - -" • "- " - ' - •"
•
FROM TO '"- ' MATERIAL EMPLACEMENT METHOD&AMOUNT•
❑Irrigation . : . .. ' ' . _ .' ft..• ': • ft. •
.. Non-Water Supply Well:
17Monitoring , " . ORecovery '
Injection Well: tt. fc
.❑Aquifer Recharge • . . ❑Groundwater Remediation • • 19.SAND/GRAVEL PACK(if applicable) ' •' -
• • . .FROM TO. MATERIAL . EMPLACEMENT METHOD '
• . ❑AquiferStorage and Recovery. ' .❑SalinityBarrier „ .
.• ❑Aquifer Test " • • • ❑Stormwater Drainage . • •
ft... • f4
' • 'oEitperiinental Technology . ❑Subsidence Control
. . 20:DRILLINGLOGadditional sheets if necess(attach ary) .. ".
❑Geothermal(Closed Loop) • -❑Tracer '. ' ' • FROM• - - . TO - . ' DESCRIPTION(color.hardness,soll/rock type,grain tee,eta).
OGeothermal(Heating/CoolingReturn) OOther.(explain under#21 Remarks). 0:0 tt. 1.0 :- ffi' GRASS/TOPSOIL
10/18/23 ' •VAP-2. . . 1 0 ft.: 15,0. ft- • • .. BROWN CLAY
4.Date Well(s)Completed: Well ID# • •
15..0.... ft. ' .55.0 ' f.. ' ' . BROWN SILTY CLAY .
5a.Well Location:
55.0 ft.:. 65.0. fn ' •GRkY SILTY"PWR:'; ;`: ;-j
• .• U NIVAR. ft.' ft. T �.
.
Facility/Owner Name - Facility TM(if applicable) tt. ft C 9
5010 HOVE ROAD CHARLOTTE 28208 - '� "1 102 •
. ft. ft. :.
Physical Address,City,and Zip • 21.REMARKS '
M ECKLEN BURG WATER SAMPLING THROUGH INFLATABLE PACKERS 1NSIbE SONIC TOOLING
County . Parcel Identification No.(PIN)
• 5b.Latitude and Longitude in.degrees/minutes/seconds or decimal degrees: 22.Certification: .
(if well field,one lit/long is sufficient)
35° 16' 07.67" N 80° 53' S3.27" w '� •
10/20/23
Signature of Certified Well Contractor, Date
6.Is(are)the well(s): ❑Permanent or filTemPorary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7;Is.this-a repair to an existing well: ❑Yes or' El No copy of this record has been provided to the-well owner.
If this is a repair,fllout known well construction information and explain the,nature of the
repair under#11 remarks section.or on the back of this form. 23:Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple,injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTALINSTUCTIOPiS
9.Total well depth below land surface: 35.0/50.0/60.0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(4.200'and 2(4)100) construction to the following:
1.
25.0
• 10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" • 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.0 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
SONIC above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: f• •
(i.e.auger,rotary,cable,direct push,etc.) .
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to.•
the address(es) above, also submit:one copy of this form within 30 days of
136.Disinfection type: Amount completion Of well construction to the county health department of the county
• where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013